Locally, our CCG is in the red. Badly so too.
It seems that being rated as ‘inadequate’ did not give it the required fillip. Nor apparently did being placed under ‘Directions’ from NHS England. So now it is in ‘Special Measures’. Ouch.
In meetings, those on the inside have for several years been blaming the problem on a national system called Payment by Results, which guarantees payments for hospital activity regardless of whether the commissioner can afford it. They pointed the finger at the ‘over-performance’ of hospital trusts, as deliciously Orwellian as that concept is, forcing them to pay up.
No matter that we did not choose our CCG, nor that any blame for its losses is ours — indeed, no matter where the cause lies — it seems making its books balance is a decidedly local burden. Information provided to practices about this promises that there ‘may be some difficult decisions and everyone will have to work hard’, as though some easy-life slackers have already been spotted lingering over their lunch breaks. We are promised ‘support’, too, presumably to help us implement those difficult decisions.
Regionally, a recent mailing tells me that a new funding project is underway to manage minor illnesses, with NHS 111 being able to refer patients to pharmacies. An evaluation of NHS 111 itself found that it did not lead to the expected reduction in service use and noted the ‘potential that this type of service increases overall demand for urgent care’.1 Whoever commissioned this additional service clearly didn’t read that, however. Indeed, it seems that an acceptable outcome for participating pharmacies is to make a sale, creating an obvious incentive for them to stoke demand too.
Nationally, at the birth of the NHS in 1948, most GPs were single-handed and working with little support other than, generally, a wife. So many things have changed since — the rise of the group practice, the burgeoning of non-medical roles in primary care, and computerisation are a few examples. But arguably the greatest impact has been made on primary care by something that changed in medical schools.
The GMC report in 2016 highlighted that most medical students were, once again, female.2 Indeed, they also report it is only among fifty-somethings that there remains a large excess of male doctors in the workforce. Bearing in mind how difficult it is to ascribe causes with any purity in a complex system such as the NHS, the impact of that gender reversal in medicine has been huge. Likely effects include the rise of part-time working and of salaried GPs.
Insights developed from the mathematics of fractals and the work of those such as Edward Lorenz, he of ‘the butterfly effect’,3 show that what happens next in complex systems is acutely sensitive to the starting conditions. What is now known as chaos theory relates how even apparently minor differences in the way things are set up at the start of a period of observation can have profound effects on how things turn out by the end.4 Even settled complex systems behave unpredictably.
What about the NHS then? There is currently so much flux: locally, regionally, and nationally. And then there are all those things that occur outside primary care but that can nevertheless have a profound impact on it, such as the changing gender balance of general practice. The cumulative effect is a tangle of poorly coordinated initiatives at every level and at every stage of implementation. Motives are mixed too. Although many are driven by the desire to cut spending, others are busily incurring new costs.
The chaos is predictable. Which means the postcode lottery is alive and kicking.
- © British Journal of General Practice 2018
